Sexually acquired arthritis

Dr A A Opaneye, Consultant GU/HIV Medicine Physician, Middlesbrough General Hospital, Ayresome Green Lane, Middlesbrough, Cleveland

Key words: Reiter's syndrome; age; reactive arthritis; analgesics; chlamydia trachomatis; antibiotics.

Introduction
A number of people (male and female) suffer from painful joints of such severity that they take painkillers e.g. paracetamol for relief or pay a visit to their general practitioners. In some of these cases the joint pain (arthralgia) is due to inflammation of the joint (arthritis) following an infection in some other part of the body. This is known as reactive arthritis. On some occasions the infection would have been acquired following sexual activities. In sexually acquired reactive arthritis (SARA), asymmetric polyarthralgia which may be migrating is the worst common presenting symptom. Some people may have one joint involved while others have several joints involved, and the common joints are the elbow, wrist, knee and ankles. Hip joint involvement is uncommon and the condition may present acutely of sub-acutely. Reiters syndrome consists of urethritis, conjunctivitis and arthritis.
Reactive arthritis may follow a bout of diarrhoea. In these post-diarrhoeal reactive arthritis, the causative organisms include shigella, yersinia, salmonella and campylobacter. People with reactive arthritis have often been referred by the general practitioners (family physicians) to the rheumatology clinics. Blood investigations reveal that they are sero-negative for rheumatoid factor and a review of their sexual history suggests re-referral to the genito-urinary medicine department for further management. The commonest sexually transmitted infection associated with reactive arthritis is chlamydia trachomatis (1,2,3). This is an obligate intracellular organism with an incubation period of between 7-14 days and it may co-exist with gonococcal infection. It causes urethritis, epididymitis, cervicitis, salpingitis, neonatal pneumonia and conjunctivitis. The organism is sensitive to tetracyclines eg deteclo; and macrolides eg azithromycin. However other microbes like ureaplasmas have been implicated in reactive arthritis (4,5).

Clinical features
The history of men seen recently in our department are shown in table 1. More men than women are diagnosed with reactive arthritis. The male:female ratio shown in table 2 may be due to underdiagnosis in women. Inflammation of the joint usually occurs within four weeks after the infection. This may be accompanied by low back pain, muscular pains and low grade fever. Other parts of the body that may be involved are the urethra, the eyes and the heart - carditis. Skin manifestations include keratoderma blennorrhagica and erythema nodosum. In some patients there may be frequent recurrence of the joint pains while in others it may become chronic.

Predisposing factors and pathogenesis
As shown in table 1, prior to attending the GUM clinic the patients were on non-steroidal anti-inflammatory medication e.g. ibuprofen. The infective origin of their condition was not realised, and delay in antibiotic treatment is a factor in joint involvement. The major outer membrane proteins of C.trachomatis include heat shock proteins which induce immunologic reactions in the joints affected. This may be why fluids from affected joints have not yielded any organism on culture, however sensitive tests have revealed the presence of C.trachomatis antigen in some people. A large proportion of those with reactive arthritis (table 2) are HLA-B27 antigen positive (3). The theory is that their genetic constitution makes them susceptible to reactive arthritis following enteric or urogenital infection. HLA-B27 is histocompatibility antigen present in all somatic cells.

Management
There are several aspects that require consideration in the management of people with sexually acquired reactive arthritis. In order to relieve their pain they need non-steroidal anti-inflammatory agents like ibuprofen. On some occasions it may be necessary for them to have intra-articular steroid injections. Screening for STD should be done and appropriate antibiotics prescribed. Chlamydia trachomatis is the commonest causative organism and a course of tetracycline or macrodides should be given. A carefully taken sexual history in people below the age of 35 years will be helpful in the early detection of reactive arthritis subsequent to urogenital infection. The patient's sexual partner/s should be contacted for screening and treatment. Facilities and procedures for contact tracing are available in the GUM clinics. These resources should be used, hence the need for cooperation between departments or health care workers. It is important to inform the patient that there may be recurrences. The role of further courses of antibiotics in recurrences is not clear (6). This is provided an initial adequate course of antibiotics has been given and the patient's sexual partner has been screened and treated.

Table 1: Characteristics of male patients with reactive arthritis

Patient	Sex	Age	Rheumatology Clinic	GUM Clinic
1	M	20 yrs Caucasian Electrician
2	M
3	M
4	M

    
A M  C/o Polyarthralgia
- hip, knees and ankle joints
Treatment: Indomethacin C/o dysuria
Discharge
Microscopy: PC+++
CHLAMYDIA: Negative
Treatment: Doxycycline
B M 20 yrs
Unemployed C/o polyarthralgia
Knees ankles and mouth ulcers
Treatment: analgesics Asymptomatic
Microscopy: PC+++
CHLAMYDIA: Positive
Treatment: Deteclo
C M 35 yrs
Gardener C/o Polyarthralgia
Swollen wrist and knee joints
Treatment: Ibuprofen C/o Urethral discharge
Microscopy: PC+++
CHLAMYDIA: Positive
Treatrment: Deteclo
D M 39 yrs
Unemployed C/o pain in knees
Treatment: Arthrotec and Allopurinol C/o Dysuria
Microscopy: PC+++
CHLAMYDIA: Negative

PC= pus cells

Table 2: Epidemiological features of SARA compared with post-diarrhoeal reactive arthritis (Shigella, Salmonella, Campylobacter and Yersinia) (7)

Feature Sexually acquired Postdiarrhoeal
Number of patients 557 767
Sex, ratio, male:female 9:6:1 1.1
Prevalence (proportion of infected individuals developing arthritis 1.0% 2.7%
Mean age (and range) at onset (years) 19 (15-59) 30 (0.5-77)
Mean total incubation period 28 20
Mean period from infection to arthritis (days)
Proportion less than 30 days 14
88%
14
87.1%
Mean period of episode (weeks)
Proportion of less than 6 months 19
71.7% 18.8
70.7%
Proportion of patients with multiple episodes 48.2% 16.4%
Proportion of patients with symptoms after 1 year 16.5% 13.7%
Proportion of patients with Reiters triad 35.2% 9.9%
Proportion of patients with HLA B27 79.5% 77.5%

References

1. Keat A; Thomas B; Dixey J; Osborn M; Sonnex C; Taylor-Robinson D. Chlamydia trachomatis and reactive arthritis: the missing link. Lancet 1 (8524): 72-4, 1987.
2. Keat A; Thomas B; Hughes R; Taylor-Robinson D. Chlamydia trachomatis in reactive arthritis. Rheumatology International. 9 (3-5): 197-200, 1994.
3. Keat A. Sexually transmitted arthritis syndromes. Medical Clinics of North America 74(6): 1617-31, 1990 Nov.
4. Horrowitz S; Horrowitz J; Taylor-Robinson D et al. Ureaplasma urealyticum in Reiter`s syndrome. Journal of Rheumatology. 21(5):877-82, 1994.
5. Taylor-Robinson D; Gilroy C B; Horowitz S; Horrowitz J. Mycoplasma genitalium in the joints of two patients with arthritis. European Journal of Clinical Microbiology and Infectious Disease. 13(12): 1066-9, 1994 Dec.
6. Rahman M U; Hudson A P; Schumacher H R Jr. Chlamydia and Reiter`s syndrome (reactive arthritis). Rheumatic Diseases Clinics of North America. 18(1):67-79, 1992 Feb.
7. Kent A; Rowe I: Reiter`s syndrome and reactive arthritis in Sexually Transmitted Diseases. textbook of genitourinary medicine. Ed G Csonka and K K Oates. Bailliere Tindall 1990.

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